MEDICARE: SHANNON GOOCH LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	70940	TX

General Provider Information

NPI Number	:	1528414307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON GOOCH LPC

Provider Business Mailing Address
First Line	:	8828 N STEMMONS FWY
Second Line	:	#225
City	:	DALLAS
State	:	TX
Zip	:	75247-3719
Country	:	US
Telephone Number	:	469-227-7847
Fax Number	:

Provider Business Practice Location Address
First Line	:	8828 N STEMMONS FWY
Second Line	:	#225
City	:	DALLAS
State	:	TX
Zip	:	75247-3719
Country	:	US
Telephone Number	:	469-227-7847
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2016
Last Update Date	:	10/07/2016

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